THE PATHOLOGY OF THE PHYSICAL ABUSE OF CHILDREN

• Jurisdiction: Australia

Epidemiology ................................................................................................. [33C.100]

The paediatric forensic autopsy .................................................................... [33C.110]

Anatomy ........................................................................................................ [33C.120]

Mechanisms of injury .................................................................................... [33C.130]

Patterns of injury ........................................................................................... [33C.140]

Bruising ......................................................................................................... [33C.150]

Abdominal trauma ......................................................................................... [33C.160]

Chest trauma ................................................................................................. [33C.170]

Burns ............................................................................................................. [33C.180]

Fractures ....................................................................................................... [33C.190]

Asphyxia ........................................................................................................ [33C.200]

Sudden Infant Death Syndrome (SIDS) ....................................................... [33C.210]

[33C.100] Epidemiology

The World Health Organisation (WHO) has estimated that every year there are 31,000 homicide deaths of children under the age of 15 (WHO, 2010).

These children are either directly killed by acts of violence or die from chronic neglect and abuse over time (Asmussen, 2010). Evidence suggests that younger children are more likely to be fatally assaulted by parents and/or other caregivers, whereas teenagers are most often killed by their peers or other adults (Asmussen, 2010). Yampolskaya, Greenbaum and Berson (2009), in a study examining 126 profiles of perpetrators of fatal assault in the United States, found that males were three times more likely to fatally assault their children, and researchers who have used police homicide records regarding fatal child abuse suggest that the majority of perpetrators are males (Lyman et al, 2003). Non-biological parents are 17 times more likely to commit a fatal assault towards a child than biological parents (Yampolskaya et al, 2009).

For the cause of death recorded on a death certificate to be attributed to assault or child maltreatment, a doctor or a coroner must ascertain either assault or child maltreatment as the underlying cause. If there is any uncertainty about the intent of the cause of death, then, according to the requirements of the International Classification of Diseases, the death may be assigned to an "accidental cause". This is likely to result in an underestimation of the true magnitude of child maltreatment fatalities.

[33C.110] The paediatric forensic autopsy

Prior to the autopsy being performed, it is imperative that other matters are considered:

• the scene should be visited wherever possible. In many cases, the child will have been removed to a hospital department; however, it may still be of benefit to visit the scene;
• discussion should be made with the hospital clinicians where the child is held with regards to metabolic sampling, washing the body or removing resuscitation equipment. These processes may remove useful evidence, for example, genetic material such as blood, semen or saliva, or create artefact such as blood within the thorax or abdominal cavity after biopsy for metabolic investigation;
• resuscitation procedures should be documented so that any injuries may be interpreted appropriately;
• if the case is considered to be a SIDS death with no suspicious circumstances, a formal police checklist should be obtained as soon as possible. These tend to vary slightly in their content between jurisdictions, but generally contain information about the circumstances leading up to the child's death, state of health of the child (and siblings), tobacco, alcohol and drug use by members of the household, sleeping arrangements of the child, etc; and
• a full radiological survey should be conducted, preferably in a hospital radiology department rather than with portable equipment, and the x-rays/CT scan should be examined by a paediatric radiologist experienced in non-accidental injury before the autopsy commences. A typical skeletal survey comprises plain films of the following:

- anteroposterior AP/lateral skull (a Townes skull also if suspicious of occipital fracture),
- lateral cervical and thoracolumbar spine,
- chest x-ray,
- left/right oblique ribs,
- abdominal x-ray,
- left/right AP humeri,
- left/right AP forearm,
- left/right AP hand,
- left/right AP femora,
- left/right AP tibia/fibula and
- left/right dorsoplantar feet.

At the autopsy, a list should be compiled of all persons present, noting the start and the finish time of the examination.

External examination

Identification should be confirmed and the body photographed clothed and then unclothed, full length, back and front. The state of cleanliness should be commented on (i.e. evidence of nappy rash, faecal and urinary staining).

Weights and measurements: The body should be accurately weighed and appropriate measurements taken (crown-heel length, crown-rump length, foot length, head circumference, chest circumference and intercanthal distance). These can then be compared with standard tables, and an assessment can be made of nutritional state.

Eyes and mouth: The eyes should be examined after fully everting the lids for evidence of injury and the presence of petechial haemorrhages. The mouth and gums should be examined for evidence of injury, looking at the buccal mucosa and noting any damage to the frenula.

Skin: The pattern and distribution of hypostasis as well as any signs of decomposition should be recorded. Congestion, cyanosis, petechial haemorrhages should be noted and that distribution recorded. Skin rashes, congenital abnormalities, birthmarks and naevi should be recorded, as should acquired marks such as previous scars.

Injuries: Meticulous and detailed examinations and descriptions should be made of all injuries. Ideally this should be marked on printed body diagrams which can be reserved as part of the record of examination. The production of these records may be later required in court. In addition, all injuries need to be photographed separately, with and without an accompanying cm scale. Traumatic lesions need to be differentiated into abrasions, bruises, lacerations, incised wounds, burns, etc; the shape and margins of each lesion should be defined; and its dimensions recorded (length, breadth, orientation to the body axis and position with reference to defined surface anatomical landmarks). The position of these lesions should also be described in terms of their height above the heel.

Bite marks: Suspected bite marks should be photographed, examined, swabbed and sampled in conjunction with a forensic odontologist (see Chapter 44 - Forensic Dentistry).

Head injuries: The scalp is first examined in its original state, photographs are taken and any trace evidence collected. Clotted blood, etc, which can obscure injuries, is then carefully removed and further descriptions made and photographs taken. It is often necessary to shave the hair from the margins of the lesion before repeating photographs. Bleeding from the mouth or nose should be recorded. Document alopecia.

External genitalia: The external genitalia and perineum require careful examination. The vulva and anus should be inspected carefully for laceration, bruising, leading, swelling or discharge. Any suspected semen stains on the body or clothing should be sampled. The vulval labia should be particularly carefully examined. Caution should be exercised in interpreting apparent dilatation of the anal sphincter as evidence of penetration, since it may become patulous as normal post-mortem change. Unless there are additional findings, such as abrasion, bruising or semen staining, an "open" anus is unlikely to be significant. In the presence of suspicious findings, samples should be taken for semen and microbiological culture. Examination of the perineum and appropriate sampling should be done in conjunction with a clinical forensic physician, where possible.

Investigations prior to internal examination: Cerebrospinal fluid for microscopy and bacterial culture which can be taken by cisternal or lumbar puncture. A small sample of skin should be taken for fibroblast culture. If this is taken from the midline of the sternum, the ellipse can be hidden in the midline incision.

Internal examination

Thoracic...